Challenges

The Ministries of Health in Nigeria and Uganda came together to improve the provision of safe contraceptive services. In Nigeria, the Ministry of Health aims to integrate family planning (FP) into the existing Maternal Newborn Child Health (MNCH) Quality of Care (QoC) network to reduce maternal mortality and strengthen the QoC for RMNCH+N. This network offers opportunities to integrate postpartum family planning (PPFP) into antenatal care and immediate postpartum care.

Progress in FP indicators has stalled in Uganda over the past three decades. The modern contraceptive use (mCPR) among all married women was 34.8% in 2016 (UDHS 2016), underscoring the need for accelerated efforts to expand access and improve service quality.

Both countries sought support from the WHO to strengthen QoC in FP services to achieve SDG goals 3 and 5.

Toward a Solution

In April 2020, Nigeria and Uganda embarked on a South-South Learning Exchange (SSLE) to overcome the FP challenges faced in both countries, using WHO’s five-step methodology as outlined in the SSLE guide.

Step 1: Define the need for and the purpose of the learning exchange

In Nigeria, a 2017 baseline assessment revealed that health workers lacked essential skills to offer safe contraceptive services, including removal of contraceptive implants and intrauterine devices. Although various quality improvement measures had been introduced by different partners, Nigeria lacked a national guidance for improving QoC for family planning.   In Uganda, progress in FP and reproductive health indicators, such as mCPR, unmet need for FP, total fertility rate and teenage pregnancy has remained below desired levels, emphasizing the urgent need to expand access and strengthen service quality.

Recognizing these challenges, both countries identified their learning needs. Nigeria’s learning need was ‘to improve quality of care in FP services across the life course programs (RMNCAH+N) and to integrate into its existing RMNCAH QoC /Quality, Equity, Dignity (QED) network’. Uganda’s learning need was ‘ to improve leadership and coordination structures at all levels of care and monitoring, with special emphasis on PPFP/post-abortion FP, to facilitate quality and rights-based FP services’. 

 Step 2: Plan the South-South Learning Exchange

In November 2020, both country teams started planning the SSLE. Due to the COVID-19 pandemic, the learning exchanges were conducted virtually.

Both countries ensured a wide participation of stakeholders, including the Ministry of Health, academia, UN bodies and professional societies. This was an important step to ensure that, following the SSLE, participants are in a position to disseminate and implement the learnings.

Both countries developed roadmaps and monitoring trackers to measure progress. They reviewed their objectives and confirmed their need to increase political support and improve the coordination structures for quality improvement in FP services in Uganda, whereas Nigeria focused on developing national guidelines on QoC for FP and its implementation to improve the uptake of FP.

Step 3: Facilitate the learning exchange

Following the kick-off meeting, five inter-country exchange meetings were held, where both countries shared their experiences and best practices to improve access to quality FP services and responded to the queries posed. This was followed by eight in-country discussions in Nigeria and six in Uganda to review the knowledge gained. Discussions were facilitated by Jhpiego and WHO in both countries.

Step 4: Support implementation of the action plan

In February 2021, both countries started the implementation of the learnings. Key outcomes include:

Nigeria:

• A national-level implementation guideline for improving the quality of care in FP was developed for integration in the existing QED network. This was followed by a landscape analysis of development partners implementing QoC in FP to ensure alignment and prevent duplication.
• The National FP training manual for physicians and midwives was revised to include quality of care. This was used to train 24 national trainers who then conducted cascade training for health providers.

Uganda:

• To improve leadership and coordination structures at all levels of care and monitoring, an operational plan to strengthen FP QoC was developed with indicators, under the leadership of MoH and the Human Rights-based approach was integrated into the overall quality indicators for FP, resulting in standardization and adoption of a National Quality Improvement Framework.
• A package for FP counseling and education was developed and used to deliver daily health education sessions during ANC, PNC and young child clinic (YCC) visits.

Step 5: Follow-up after the learning exchange

Each team developed and shared a report on the learning exchange. The achievements and lessons learnt from the exchange were shared at the International Conference on Family Planning, 2022.

Key lessons from the SSLE include:

• Country-driven approach: The success of the learning exchange was rooted in strong national ownership and commitment from stakeholders and policymakers. Aligning the exchange with ongoing country priorities generates commitment, greater engagement, mobilization of in-country resources and country-led implementation.
• Standardised process: A systematic process was used to guide the SSLE throughout the 5 steps, enabling uniformity and consistency both within and across countries, as well as identification of enablers and barriers in conducting the SSLE. The SSLE guide has proven to be a valuable tool for guiding the process.
• Implementation of learnings: SSLE should not be limited to the exchange of information amongst a few participants. To ensure effective implementation, Uganda and Nigeria ensured that the process was led and coordinated by the Ministry of Health. They identified Jhpiego as an implementing partner to support and coordinate the process.